Very well said.  And I support my collegues 100%, whether you work in an office, have your own practice, or work in a hospital.  We are nurse practitioners with similiar training.  I support my peers that give quality care and are a positive influence on our profession.  It is not about where you work, but the quality of care you provide and the image you portray. Does anyone know any other profession who puts down their peers as in nursing?  We struggle for respect and to expand our scope of practice laws.  How can we be taken seriously when as peers we can't support each other. 

I am happy to see the spirited discussion that my op-ed article provoked.  I was somewhat surprised as I was disappointed by how much Advance edited what I submitted. I thought they turned a very harsh commentary into something somewhat soporific.  For those of you who are interested, what follows is what I submitted in toto. 

Best regards to all my collegues,

Michael

At What Price Visibility?

 

Support for retail clinics and/or working for retail clinics, is harmful to Advance Practice Clinicians.  In the push for visibility we are sacrificing the full scope of our professional education to the benefit of big business. The retail clinic operators will use us as a simulacrum of a true health care provider.    A PA or an NP in a retail clinic does not fulfill the role of a complete practitioner.  The clinics owned by big business will be parasites on health care diverting medical dollars from the system that badly needs the money. The Nurse Practitioner or PA who works in these clinics sacrifice integrity, the broad scope of their education and training for visibility and for easy money and promotes the “dumbing down” of our professions.

 

 

 

In January of 2004 I opened my very own family practice clinic. I was tired of seeing patients in the Emergency Department whom I thought were receiving less than optimal care from their primary care providers.  I was convinced that I could do a better job.  My wife was tired of hearing me complain about the poor care these people were getting and advised me to do something about it.  . With North Carolina requiring a supervising physician, I paid a physician a thousand dollars a month to ‘be available for consultation.’  She collected her money and never once stepped into the clinic.  I fought hard for respect in the local medical community and had to withstand inappropriate attacks by local physicians.  For example, a local MD complained formally to the North Carolina Medical Board about my newspaper ad stating my board certification.  One day an investigator appeared unannounced in my office in the middle of a patient day.  When I inquired about what I could do for her, she showed me the ad, told me of the complaint and that she needed to do an investigation.  I asked what the problem was and she responded that only doctors can be board certified.  As she had a copy of  the applicable North Carolina Law regarding NP practice with her, I pointed out the part about Nurse Practitioners MUST be board certified to be licensed in our state.  I asked her if there would be anything else.  She replied that she still had to do a complete investigation as there had been a formal complaint.  At that point she demanded all my CME documentation, a copy of the collaborative practice agreement, OSHA compliance documentation, copies of  CPR, ACLS, Board certification and so on.  This constituted a 2 hour, extremely stressful interruption in my day and interfered with patient care.

     Well, anyway I survived and thrived and now own and operate 2 clinics with a 3^rd on the way and now employ about 20 people including 3 full time NP’s and a full time MD, and a part time NP.  I am included in the local medical society meetings and get primary care referrals from specialist offices.  Recently, my first clinic, the one I started 4 years ago with  an LPN and a receptionist, was voted best practice in the annual “Best Of” poll conducted by the local newspaper in a local population of over 200,000. I got to this point by providing quality, complete primary care in an office setting. This brings me to the point,.  Advanced Practice Clinicians or APC’s (a term for Nurse Practitioners and Physican Assistants) have worked very hard to establish themselves as educated, trained, and capable of being complete primary care providers.  Retail clinics are a real and certain threat to the gains we have made in the last 25 years.  

 

 

 

Nurse Practitioners and PA’s are good for routine things like sore throats and colds but for complicated things you need a “real doctor”.

    

 

If the preceding statement offends you or makes you angry, or just seems plain wrong, then how in the world could you possibly support the retail clinic model?   This reflects an archaic paradigm that needs to be buried once and for all. 

I stated my concerns about this to the American College of Clinicians (ACC) Board last year in Boston.  I repeat them now.  By defending the menu of limited basic medical services that retail clinics offer and then being force to defend them “…as surely an NP can handle this simple stuff,” we therefore imply that, and propagate the myth that for anything complex, you need a Doctor.  We must be very, very careful here.  I have seen too many promotions and defenses of retail clinics making the case that it is just little stuff so that the public is safe.  NP's and PA's are educated to do much more than that.  In the past several months I have made many unusual or critical or life saving diagnoses.  Some of these were missed by physicians.

I am not unique in the APC world and I have picked up a primary lung cancer in an asymtomatic patient, a CML, and mono in a 7 y/o, I picked up an abdominal aortic aneurism and a tri-fascicular block with a reactivation of EBV in an 84 y/o who had been 3 times to his internal medicine doctor in the past 4 months complaining of fatique and loss of appetite.  I saw him because his children were my patients who dragged him to me because they had faith in me.  We all have similar stories.  I know that the HgA1C of my type 2 diabetic patients would compare favorably with any provider's practice.  And the same goes for HTN and Lipid management.   The case that must be made proactively is that Nurse Practitioners and PA’s are health care providers in the full sense of the term and capable of managing much more than a very limited scope of patient care problems  We must not allow ourselves to be pushed into the corner defending our competence in diagnosis and treatment of routine medical conditions that most of us could do in our sleep. And this is where retail clinics are pushing us.

 

 

 

 

I can provide quality medical care when my clinic has insufficient provisions for examination,  bathroom,  and patient privacy.

 

Any arguments here?  Of course, the response is obvious, but……I have seen this issue addressed with the comment, “……hasn’t he ever done an exam in a wheelchair?”  The answer is “if I have to.”  But I wouldn’t dream of opening a clinic without adequate equipment that is the standard for care.   Having been a responder in the National Disaster Medical System for the past 13 years, I know all about medical care in the austere environment and our military APC’s really know all about sometimes having to make do.  But, I submit, in a clinic that is open every day, making do is not good enough.

 

I think the retail clinics are a good alternative source of medical care.

 

Why?  The ‘raison d’etre’ for these clinics  has nothing to do with patient care, and has everything to do with making profits.  Let’s examine some of the basic economics for a moment.  Retail clinics advertise 15 minutes and $60.  Okay, that equates to 240 dollars per hour.  If the NP is making $50 per hour, that leaves $190 per hour to cover overhead which is extremely limited being ameliorated by a small space in a larger retail space.  If the NP is reception, nurse, and provider, how much overhead is there?  Phone system is in place, utilities in place, parking in place, how much more in expenses is there?  Let’s suppose the worst care scenario for the retail operator.  Add 40% to the $50 per hour for a nice benefit package, FICA, etc making a provider cost of 70 per hour.  Add a receptionist and other expenses to total 30 dollars per hour.  All right, now you have fixed costs of $100 per hour and generating 240 dollars per hour.  Hmm, let’s see, $140 per hour X 12 hours per day times 360 days per year.  Equals a profit of $604,800 per year.   However, if you staff this clinic with part timers without benefits add 240 dollars per day to your profit for a grand total of $692,400 per year. 

     I wish that I could get reimbursed $60 for a sore throat visit which would either be a 99212 or 99213 visit.  I might get $35 and out of that pay for a rapid strep test, staff to perform it, as well as utilities etc. 

 

 

 

 

I think it is a good thing that medical care decision making is being done by MBA’s at the health insurance companies.

 

If you disagree with that statement, you have to be against the retail clinics.  These clinics take control from medical professionals and put it is the hands of the business managers. This is what many see as the great flaw in our current system.  Why should we help propagate a broken paradigm?  We rail against the fact that Medical decision making is being done by bean counters in the managed care insurance companies.  This is the same thing.  To decry one and support the other is hypocritical.

The clinics operate on a simple cookbook basis with a very limited menu.  Methodology, costs, times, are all prestructured.  And all this without the responsibility of follow up care and treatment is certainly contradictory to what I was taught.   I have heard too many NP’s and PA’s glorify these clinics because they promote visibility to our professions.   I agree that they DO promote visibility but in a very negative way.   They propagate the myth that we are Mid Level Providers.  I ask you, midway between what?  In court, there is one standard of care for all providers.  We are threatened by these retail clinics.  What an easy job.  No brainers and refer anything resembling a problem or chronic illness to a doctor’s office.  When I get a simple UTI or strep throat interspersed among my diabetic, hypertensive, dyslipidemic, obese patients with ED or recurrent vaginitis, infertility, regional pain syndrome, HIV positive,etc.   I think great, a break., a little interlude of mental down time.

Primary care in this country is suffering.  The best and the brightest of the MD’s/and DO’s  are more and more going into the high profile, high paying specialties and neglecting primary care.  I am thankful that the Advanced Practice Clinicians are filling this void. Medical groups and politicians are bemoaning the lack of primary care providers in this country.  The time is now for us to stand up and declare “HERE WE ARE!  Look at us, as we are the solution;” instead of promoting our professions  in a way that creates problems instead of solving them. 

 

All of us in the nursing profession understand and enjoy the vast amount of specialization and diversification in workplace settings.  Retail health is just that; another setting in which we can offer professional, evidence-based, personalized patient care and education that we have all been formally trained to provide.  Nurse Practitioners are lucky that there is such an opportunity to provide healthcare in this setting.  We have standardized formal education and national certifications that we all must pass in order to even practice.  Our choice of practice settings has not minimized our profession and ability to develop effective patient-practitioner relationships and offer the best patient care we can. It has added another dimension and increased the public's awareness of who we are and what services we can provide for them. Instead of sneering at your colleagues for choosing to focus their practice on treating "minor illnesses", perhaps we should support our profession and all that we have to offer to our patients.

It is really sad when ignorance and arrogance create negative opinions and ideas.  Although the NPs working at retail clinics do not deal with all health conditions, they have a very strong, positive effect on the resolution of the health conditions that they treat.  I have worked in the retail setting for 6 months, and have been able to help many people during that time.  But most importantly, I have begun to teach the community that I work in what a Nurse Practitioner is.  There are countless patients that ask "what's a nurse practitioner?"  So is it better to not be known at all, then to be known for helping people in approved, safe situations?  Also, the guidelines that we use to treat conditions have been created using the most up to date evidenced-based research - we don't just treat conditions, we treat conditions appropriately.  When I interviewed for a family practice job within a doctor's office setting, I was appalled when the physician told me "none of our patients have viruses."  It is so disturbing the number of physicians, NPs, and PAs that are working in office settings, giving patients what they want to keep them as patients - mostly antibiotics for upper resp infections.  At least when I work in the retail setting, I can educate patients about treating conditions appropriately - I'm not in a position to please the patient so they continue to be one of the patients in the practice.  I just use evidenced-based knowledge to help them in anyway I can - if they are unhappy because I didn't give them an antibiotic for their URI, at least they know why, and they don't have to come back, it is their choice.  I have also had many patients comment after their visit is over that "my doctor never told me that"  in regaurds to a prescription or a method of symptom relief that we discussed.  NPs in the retail setting provide a tremendous amount of patient education, something many patients that have been seeing doctors for years have never experienced.  It is not surprising that NPs and physicians who provide primary care do not support retail clinics - it is competition for them.  If I can provide convenient, safe care for patients, that includes patient education and explanations, the patients will prefer it over a visit to their PCP.    It just does not make sense for someone to be unfairly negative about retail clinics that provide specfic, safe, thorough patient care, unless they are personally threatened in someway.  It seems that is the true motivating factor in Michael's response. 

I could not be happier with my position in the Minute Clinic. There are set guidelines have established practices within which we all practice. Other clinics do not have accreditation and guidelines which are dangerous to me. All of our group is board certified and skilled professionals. I would like to answer any questions you have.

I have not read the article but from reading all the post I have a general idea of the theme. I have to say that having worked in the retail health arena I am adamantly against these types of clinics (this comes from my own experience, other clinics may be different). The majority of these clinics are poorly managed and staffed leaving the provider to perform multiple roles and working long hours. Often times offices within the same organization are not educated or are simply ignorant of the scope of care available at these clinics and therefore make inappropriate referals (I have had patients with chest pain refered by their family practice clinic one more than one occasion). Furthermore, these clinics attract clients with the preconcieved notion that because they pay an up front cost they are guaranteed of a antibiotic prescription where one is often not necessary. These clinics are also often restricted to following protocols for care which require no decision making ablity by the provider, this is further complicated by the fact that other providers in family practice office are not then held to the same standard and often then prescribe inappropriate medications (I have had multiple providers placate, patients with Azithromycin, which is grossly over used and often ineffective, for viral illnesses such as Mono). It is poor quality care as it is based solely on volume not quality. I think a higher quality clinic would be based out of a family practice office with one provider seeing only urgent care patients. Healthcare should never be based on volume or who is the cheapest (this does not mean that outrageous costs should be incurred either). I think we need to begin holding patients and the insurance compainies accountable for healthcare. Patients need to stop abusing the system by making some effort at self care and accepting the fact that most times a cold is just that, and that medication is rarely required for most routine illnesses. The concept of HRA's with major medical coverage is great. Patients are then held finanically responsible, including medicaid patients, as when this money is used up they then need to pay out of pocket. Insurance and drug companies also need to come under greater control.  Drug companies do not operate in a free market and often have a monopoly on medications this is hardly free enterprise. There is no easy solution to the healthcare crisis and retail health is by far not the answer but just another problem.

I could not have said this any better. Anyone taking this type of position is doing so at the detriment to their profession.

In response, I'm not sure of your training and I would never want to question anyones nursing background; however, the variety and skills of N[Ps is a varied as the RN.  We all have different backgrounds and experiences.  Our training is for the basic health problems.  I have worked as a Nurse Practitioner for seven years.  I have worked for physicians who have asked me to do things that were not included in my training.  I am aware that each Nurse Practitioner trains at different levels with different preceptors, but to be fair we should focus on our actual training.  There are Nurse Practitioners performing surgery.  I don't remember that course in my Family Nurse Practitioner program.  There are nurse practitioners out there who want to work in the Hospitals and Acute Care Settings.  This is not what Family Nurse Practitioners were trained to do.  We were trained to treat common illnesses that present commonly.  The retail based clinics are/were created to help the person who is sick when they are sick, not when it's convenient for the Physician to see them.  The reality is that if these same patient's were to call their PCP, they would be seen by the NP/PA anyway. 

In response to the limited scope, do you really think the AMA is going to let us set up an independent practice setting.  Think about it.  I know I've tried to set up my own practice.  Try to find a protocol physician to allow you to do this.  Of course, I could have paid a Physician more than I was making to accomplish this goal, but then why bother.  I think we all need to look at the bigger picture.  The Retail Health Clinics are setting up clinics that will allow ARNP's to work in autonomous setting.  Yes we are limited by guidelines, but isn't that what protocols are all about.  This is what the physicians who sign our protocols are comfortable with the NPs treating at this time without their direct supervision.  They haven't trained us and don't know the in's and out's of each NPs training and background.  As our protocol physicians and the community at large becomes more comfortable with our practice, I am sure our protocols will broaden.  We are adding new services monthly.  I would also like to point out that the biggest hurdle is to convince the MD's that we are not trying to take their patient's.  We are simply trying to help care for the patient population at large.  We encourage patient's to seek our at PCP for those chronic conditions that we feel a PCP is the best person to treat.  We may have just been the provider that diagnosed the problem in tha 40 year old who never goes to the doctor.  This is what I remember in my training.  Healthy People 2010 screening, prevention and REFER.  Thank you for taking the time to read.  I love my job.  I wouldn't trade it for a position that requires me to be subjected to the second best provider in a practice.  This is my practice and I am well trained to perform my duties as a Family Nurse Practitioner.  Nedra J. Miller ARNP, MSN  Tampa, FL

Every office has a bottom line to meet. I just had my days cut in the office I work in because of the "bottom line". In a retail clinic environment, you can work as many days as you want and get paid better than the average NP salary - at least in my area. So, don't pull the plug unless you have a back-up generator.

I have the disadvantage of not having read the article by Mr. Marks. As a NP,who works in a retail clinic, I have had similair questions about the scope of practice, about NP's falling into the same position as RN's have had in hospitals and my own companies lack of respect for the NP as a professional. So far, I am still questioning.

Retail Health Care is very new and I believe in the concept so I am not ready to throw the baby out with the bathwater. My hope is that NPs can stand up and not be forced into the role of "cheap help". The company I work for is balanced to go either way. It is verbal in it's respect and our Medical Director appears to understand our worth. time will tell. It is my hope that an open forum of discussion can facilitate the growth of Retail Health in a way that helps the profession. I can see the way it helps our patients and could, in the future increase it's role in education, prevention and health maintenance.

Today, it is the Medical Associations that are regulating how a retail clinic regards it's practice and Practitioners. I would hope that more Nursing Organizations would lead, not follow, to prevent our profession from being abused. The ANA has a set of Standards for Retail Nurse Practitioners that seems to say little and have less impact. If nursing has standards of practice, how do the credentialing boards inforce them? Until we, as nurses, learn to inforce our own standards, we continue to be used in ways that diminish us. I would prefer a professional organization stand for my profession. In the past, in my state, there has been little done. Would a union organization be more effective? I have these questions but not answers. I think our profession could use the power we could have to control our own growth. It is my opinion that our organizations could have more say in our profession if we had more backbone to stand. If money is the only way to have backbone, then we need to provide money.

 

 

I don't think that any of us entered this profession to "pick and choose" our patients that we want to care for. There is a need in our country for a group of people to get health care, and they cannot get it at the existing settings. That is why an additional option was added, to allow more people access to health care. Those who think that this is limiting the NP's scope of practice - then this is not where they should work. Not everyone can work everywhere. This is a place for those who think that this is a great opportunity for getting health care to those who otherwise cannot get it. Who perhaps did not have it for many years, and perhaps would not have for many years if retail clinics did not exist. This is a great opportunity to do a quick screen - like Synthia mentioned - high blood pressure, symptoms of another chronic condition etc, and refer. This is even a greater opportunity to try and do some health education - smoking cessation, healthy eating. Yes, I know that in the 15 minutes that are alloted to the visit it is hard to fit all that - and I also know that the patient may not even llisten - but we must try, because this is our mission.

I believe that we all should work where we feel good about what we do, and respect each other's choices. There is nothing that an advanced practice nurse does in the way of providing health care, in any capacity or setting, that shows us in a bad light. Actually, it shows that the NP is willing to do anything it takes to provide health care, and that is respected by the public. Show me another discipline who is willing to do that.